I, certify that I have been informed:- of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule; of the likely cost of this treatment; and that I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funds being available under the benefit cap.
form is valid up to 31 December of the calendar year for which it is signed